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Wednesday, January 16, 2008

how many residents does it take to to screw in a light bulb?*

Young doctors on the whole are extremely egocentric. Not in the way you think--I don't mean that we all think that we're God's gift to humanity (even there are though some of those among us clearly do think just that), but what I mean is that we tend to think that many things that happen somehow reflect personally on us, though they often do not.

One example I can think of is with patient outcomes. If a patient I have taken care of has a bad outcome even days out from the surgery, I immediately think that it must be because of something I did to them. Never mind that they were sick as shit before I got to them, that the fact that they crashed and burned had more to do with florid sepsis or a crappy heart or a liquefied liver or evil humours, and less to do with, say, the expertise of, say, my fiberopticintubation. Not to generalize, but I think more senior physicians tend to take bad outcomes a little bit better, just because, having been around the block, the know that sometimes despite best efforts, Bad Things Just Happen. For a junior physician however, we develop a little tunnel vision sometimes, and figure that anything bad that happens must be because we did something wrong. I should have done this. If only I had done that, then maybe it would have turned out differently. It's conceit, in some ways, but mostly, it's just inexperience.

Another example is Resident Paranoia. I will apply it specifically to anesthesia, since that's what I know, but I'm pretty sure that you can apply it to other fields as well. Each afternoon, the OR schedule for the following day is released, and the room assignments are issued as well, where residents are assigned to each OR, depending on what service they're rotating through that month, what year resident they are, and the difficulty level of the case. For example, first year residents will often get assigned to rooms with healthy patients having, like, hemorrhoid surgery, whereas a more senior resident might get assigned to bigger cases, like liver transplants or major vascular surgery. The same probably applies for surgical residents, and obviously, it makes sense. The more experience you have, the bigger cases you're able to handle, and with more independence.

However, there are only so many "big" cases each day to go around, and they (you know, the attendings in charge) try to split these up among the seniors throughout the week to be fair. What this means is that every day, there are at least a few senior residents doing "smaller" cases (in quotes because we all know that there are NO SMALL CASES, only small doctors, right?), and there is always internally some speculation about who got assigned to the "bigger" cases and why. "I got stuck in the hernia room today? What did I do wrong? Maybe they think I can't hack it in the Whipple. Why didn't they put me in the reop-hepatectomy? Maybe they think I'm dumb." Like I said, we are a paranoid bunch.

And we have short memories too. Monday, I did a huge case, but the two days since then I've been doing anesthesia for thyroid surgeries and hernia repairs. So of course I think that I'm being PUNISHED and I'm worried that they're not putting me in the BIG LEAGUE ROOMS because they somehow don't think I can HANDLE it or something. Maybe because they know that I'm not taking the Boards on time and now they don't TRUST me or something. Put me in, coach! Just put me in the game!

Not until I talked to two other residents in my class, who respectively have been stuck in the Gyn rooms and in the cystoscopy suite for the past two days that I am more reassured that it's not necessarily that they think I'm an idiot only capable of handling the anesthetic challenges presented by a varicose vein stripping--and more that they have a lot of senior residents on the roster, and just need someone, anyone, to staff the OR.

Anyway, it's good to do bread and butter anesthesia once in while, right? And anyway, if they put me in huge cases day after day, I'd be totally burned out by the end of the month. It's kind of nice sometimes to do a nice, calm little case. You know, to have a relaxing day for once. So it's good. The attendings in charge know what they're doing.